Recent reports in the media have created a big fanfare when the FDA announced the approval of a Heroin Vaccine. It is portrayed almost as a panacea for the heroin epidemic in this country. Without diminishing its fit of scientific breakthrough, let’s discuss some aspects of the physiology and neurobiology of addiction.
It takes the blood only a few seconds after the heroin injection to reach the brain mu opioid receptors, even faster with newly available inhalation way of delivery. So how effective will the vaccine be in neutralizing the heroine in that timespan?
Any vaccine for common infections acts by creating a pool of antibodies, aimed at various parts of the bacteria or virus, circulating in the body. And those become activated usually via a cascade of events once the culprit bacteria or virus enters the body. For a typical infectious disease there is a latent time known as prodrome (time between agent entering the body and person developing actual symptoms) that lasts days and gives the body time to mobilize the defences/recruit those antibodies. I am curious to learn how the scientist were able to bypass that delay.
One should further wonder, will the efficacy of a neutralization of heroin be dose dependent? (the more you inject the less effective the vaccine?) What about repeat doses? A typical drug addict uses heroin several times a day, so the more frequently you use, the less effective the vaccine should be since there is only a limited amount of antibodies circulating in your system at any given time.
Let’s consider another aspect – they say the vaccine could last for years and may be effective against some commonly abused prescription opiates. Then what about those people who were vaccinated and will need, at some point down the road, pain management for a legitimate medical condition? If opiates won’t work how will you manage their pain and most importantly how much more costly will their care be if you have to use alternative modalities, higher doses, higher level of care (Telemetry or intensive care unit) due to the increased need for monitoring of vitals when given high doses?
Let’s also consider the ethical aspect of this – although the vaccinations should be done on a freewill basis, it appears to be more applicable for “repeat offenders”, i.e. persons with high rates of relapse, frequent overdose presentations or those with pronounced psychiatric co-morbidities who are at a higher risk of relapse. And those will be the ones who are likely to volunteer to be vaccinated the least. The rest of addicts, who are determined on staying in recovery and to remain sober, appear to be the prime target for the vaccine, yet they are the ones who would need it less since they already do well on their MAT pharmacological therapy. And of course, for the rest of heroin uses, 90% of all addicts, who are out there still enjoying getting high, I wonder what is the plan in place to entice them to line up in queues for the vaccine?
People have to realize that once they are vaccinated it creates a semi-permanent condition in which their body is altered. This psychological aspect is the biggest impediment for addicts to embrace currently available long-acting options such as naltrexone Implants, buprenorphine implant of sublocade injection. By the same psychological association, it makes one wonder how many people will line up for vaccination treatment?
Here is a historical example – the recently introduced Naltrexone implant. A seemingly perfect option to recover for somebody who struggles with heroin or alcohol dependence and introduced to the market with a big bang, yet to date still remains a treatment very rarely sought after. It might be that it was cost prohibitive, however it is typical human psychology to be wary about having something permanent added to, or something that long-term alters their body. Typical humans prefer to have control over their treatment, i.e. have an option to make a choice whether to take or not to take the medicine, or whether to discontinue or continue the treatment. In the case of either implant or vaccine, the person’s ability to make that choice is limited.
Therefore, vaccination could and should only be mandatory for people with overdose recidivism and who consume a large proportion of healthcare costs due to their repeated hospitalizations. Perhaps, also for prison inmates who are opiate users as well, as long as drug use is unavoidable in the correction system.
It is not far-fetched to surmise that heroin manufacturers will very soon alter the product slightly to be able to avoid detection by antibodies to bypass the heroin vaccine blockade, as well as introduce different synthetic opiates on the market that will not be neutralized by the vaccine. This is why the anti-viral vaccines have limited efficacy due to frequent mutations of the viruses.
What will likely ensue after the introduction of the heroin vaccine is another “arms race” akin to one we had for decades between us with antibiotics, against microbes and viruses that invariably become antibiotic resistant sometime after exposure to newer drugs, forcing the development of newer antibiotics.
Let’s go back to a brief review of physiology, psychology, and neurobiology of an addict’s brain. Once drug use or alcohol dependence is maintained, it sets a system of neuronal connections that become very strong via the process called reinforcement, and this determines how a person from now on will behave, think, and act, for years to come-if not lifelong. After that, any intervention that is based on forced abstinence, with or without medication assisted therapy (MAT), will not be effective long-term unless you help the person with chemical dependency weaken or “rewire” those connections.
Because of those set neuronal connections and the way they influence an addict’s behavior, when you deprive the brain from the biggest reward it has been wired toward, It will eventually find a different drug or behavior activity to substitute the missing “rush”. For example, somebody who has been abstinent from alcohol through forced abstinence often times relapses to opiates down the road and vice versa, you see a high chance of relapse among opiate addicts to alcohol, cocaine and so on. This is exactly why they call Substance Use Disorder (SUD) a chronic relapsing brain disease. And this is why part of our current patients maintained on Buprenorphine (Bup) based product, still relapse on other drugs, nicotine, gambling and so on because Bup does not change how their brain reward system was wired. Therefore, your ideal heroin vaccine patient will have a higher chance of relapsing down the road on another drug/behavior in order to fill the void created by the cessation of drug use for their brain will lead them to do anything without them even realizing why, to put “that candy back”.
All this begs the question, why reinvent the wheel when we already have very effective treatment options for opioid addiction? Buprenorphine works extremely well when coupled with an intervention aimed at “rewiring” the addict’s brain during the taper off the buprenorphine. The process of requiring effort on the part of a patient during which he or she learns how to acquire rewards from healthy adrenaline evoking activities, a sure way to avoid relapses in the future.
Therefore, only using the well-known and effective principle of pharmacological extinction applied during once recovery from alcohol or opiate dependency, started even during their maintenance, like in a MAT program, will assure sustained recovery and lack of relapse. It appears that it makes sense to direct funds away from development of novice treatments of questionable efficacy, but rather direct effort on public education to avoid drugs and to decrease the demand for drug use. On the other hand, for those who are currently in treatment, to fund specially structured facilities that will allow active users to recover through an applied pharmacological extinction method.
And on a personal note, those addiction medicine providers who still believe that an opiate addict should be on suboxone lifelong, clearly are reading the wrong materials or are serving the interest of themselves or worse–the Big Pharma Industry.
In conclusion, let’s focus on creating conditions where we, the SUD treatment providers, will be able to offer pharmacological extinction for those on heroin. Yes, it will require a joint effort of legislators and political will. We need to focus on partnering with, and collaborate alongside those who are genuinely interested in a real opiate epidemic cure, and let the rest to continue merely talking about the problem while enjoying media PR publicity.